Executive Summary: Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Stroke (Impact Factor: 6.02). 05/2012; 43(6):1711-37. DOI: 10.1161/STR.0b013e3182587839
Source: PubMed

ABSTRACT The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).
A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.
Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.
aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

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Available from: Juan Ricardo Carhuapoma, Aug 16, 2015
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    • "The main therapy against SAH is securing the cerebral aneurysms and treating the cerebral vasospasm, which develops in 70% of SAH populations between 3 and 14 days after SAH onset [3]. Cerebral vasospasm causes delayed cerebral ischemia and contributes to the major cause of poor outcome and even death in SAH patients [1], but so far there is no definitive treatment against the devastating complication. "
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    ABSTRACT: Cerebral vasospasm is the leading cause of mortality and morbidity in patients after aneurysmal subarachnoid hemorrhage (SAH). However, the mechanism and adequate treatment of vasospasm are still elusive. In the present study, we evaluate the effect and possible mechanism of progesterone on SAH-induced vasospasm in a two-hemorrhage rodent model of SAH. Progesterone (8 mg/kg) was subcutaneously injected in ovariectomized female Sprague-Dawley rats one hour after SAH induction. The degree of vasospasm was determined by averaging the cross-sectional areas of basilar artery 7 days after first SAH. Expressions of endothelial nitric oxide synthase (eNOS) and phosphorylated Akt (phospho-Akt) in basilar arteries were evaluated. Prior to perfusion fixation, there were no significant differences among the control and treated groups in physiological parameters recorded. Progesterone treatment significantly (P < 0.01) attenuated SAH-induced vasospasm. The SAH-induced suppression of eNOS protein and phospho-Akt were relieved by progesterone treatment. This result further confirmed that progesterone is effective in preventing SAH-induced vasospasm. The beneficial effect of progesterone might be in part related to upregulation of expression of eNOS via Akt signaling pathway after SAH. Progesterone holds therapeutic promise in the treatment of cerebral vasospasm following SAH.
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    • "Although the ideal target BP to reduce the risk of rebleeding has not been established, a decrease in systolic BP to <160 mmHg is recommended as reasonable in the latest guidelines (Class IIa; Level of Evidence C) (Connolly et al. 2012). This may be achieved by using a readily titratable drug to balance the risk of stroke, hypertension-related rebleeding and maintenance of cerebral perfusion pressure (Class I; Level of Evidence B) (Connolly et al. 2012). "
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    ABSTRACT: Three-dimensional CT angiography (3D-CTA) is increasingly used in the initial evaluation of subarachnoid hemorrhage (SAH). However, there is a risk of aneurysm re-rupture in the hyperacute phase. We sought to clarify the incidence of re-rupture and characterize the subgroup in which extravasation of contrast media was seen on 3D-CTA. We examined the records of 356 consecutive patients presenting to our institution with non-traumatic SAH between October 2003 and December 2011. After resuscitation, patients with poor grade SAH underwent CT then 3D-CTA while sedated, mechanically ventilated and with a target systolic blood pressure of 120 mmHg. 336 patients underwent 3D-CTA; 20 died without return of spontaneous circulation. Extravasated contrast medium was seen in 16 (4.8%), 15 (4.5%) at the initial evaluation. Their World Federation of Neurosurgical Societies Grade was V; one patient was resuscitated from cardiac arrest. The mean times from onset to arrival and to CTA were 43.7 minutes and 71.8 minutes, respectively. Ten patients (62.5%) had episodes suggestive of aneurysm re-rupture before 3D-CTA. Surgical clipping, evacuation of hematoma and wide decompressive craniectomy was completed in six patients and one underwent coil embolization. Two of 16 patients survived: one with moderate disability and one made a good recovery. Contrast extravasation was detected by 3D-CTA in 4.5% of cases despite intensive resuscitation, suggesting that continuous or intermittent rebleeding may occur frequently in the hyperacute phase. The consequences of rebleeding are devastating; however, favorable results can be obtained with immediate aneurysm repair with decompression and intensive neurocritical care.
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